Community ownership and participation
Health systems can be transformed to deliver better health in ways that people value: equitably, people-centred and with the knowledge that health authorities administer public health functions to secure the well-being of all communities. These reforms demand new forms of leadership for health. The public sector needs to have a strong role in leading and steering public health care reforms and this function should be exercised through collaborative models of policy dialogue with multiple stakeholders, because this is what people expect and because it is the most effective.
A more effective public sector stewardship of the health sector is justified on the grounds of greater efficiency and equity. This crucial stewardship role should not be misinterpreted as a mandate for centralized planning and complete administrative control of the health sector. While some types of health challenges, for example public health emergencies or disease eradication, may require authoritative command and control management, effective stewardship increasingly relies on “mediation” to address current and future complex health challenges.
The interests of public authorities, the health sector and the public are closely intertwined. Health systems are too complex: the domains of the modern state and civil society are interconnected, with constantly shifting boundaries. Effective mediation in health must replace overly simplistic management models of the past and embrace new mechanisms for multi-stakeholder policy dialogue to work out the strategic orientations for primary health care reforms.
At the core of policy dialogue is the participation of the key stakeholders. Health authorities and ministries of health, which have a primary role, have to bring together:
- the decision-making power of the political authorities
- the rationality of the scientific community
- the commitment of the professionals
- the values and resources of civil society.
This is a process that requires time and effort. It would be an illusion to expect primary health care policy formation to be wholly consensual, as there are too many conflicting interests.
However, experience shows that the legitimacy of policy choices depends less on total consensus than on procedural fairness and transparency. Without a structured, participatory policy dialogue, policy choices are vulnerable to appropriation by interest groups, changes in political personnel or donor fickleness. Without a social consensus, it is also much more difficult to engage effectively with stakeholders whose interests diverge from the options taken by primary health care reforms, including vested interests such as those of the tobacco or alcohol industries, where effective primary health care reform constitutes a direct threat.
This section of the Community ownership and participation profile is structured as follows:
The involvement of the community is critical for health service delivery and ownership in Liberia. The National Health Plan elaboration process involves the community as a major stakeholder in the sector.
During the development of the National Health Plan, a series of county-level consultations was held in conjunction with various communities to identify health priorities and the causes of morbidity and mortality. It is envisaged that community involvement in the planning process will generate ownership and facilitate the implementation of the Plan.
Community ownership and participation in the health sector is vital for sustainability, local resource mobilization and decision-making. As part of the decision-making process, Community Health Development Committees have been established to support the Government of Liberia's efforts to improve service delivery.
Also, under the performance-based contracting scheme, implementers are required to establish, strengthen and engage Community Health Development Committees as part of the performance indicators. These Committees are responsible for providing support and oversight at health clinics to ensure better coordination and collaboration between the health facility and the community. The officer in charge of the health facility serves as secretary to the Committee.
Resource mobilization is an important component of the health system. In Liberia, part of the community involvement and ownership arrangement includes the provision of land and materials (e.g. timber, bricks, rocks and sand, etc.) for construction of health clinics. Communities are also mobilized to provide accommodation for rural health workers, especially certified midwives, who accept assignments in hard-to-reach rural communities. Community Health Development Committees are also involved in building fences and digging waste pits for clinics and motivating community health volunteers.
To ensure that the Essential Package of Health Services is provided and that health services are accessible and reach the vulnerable population, the role of the community is essential. Community-level health interventions such as immunization; antenatal care; family planning; health promotion; home-based management of diseases such as malaria, diarrhoea and pneumonia; disease surveillance; and referral services cannot be adequately provided without the full participation of community health workers.
The Essential Package of Health Services has identified that a standard set of outreach, health promotion and referral services should be provided for communities more than 1-hour's walk (5 km) from the nearest health facility. In Liberia, community health volunteer services include household health promoters, trained traditional midwives and general community health volunteers.
Community health volunteers, especially trained traditional midwives, are key service providers contributing to the improvement of maternal and child health services. Where there is no physician assistant or certified midwife, which is common in many rural and hard to reach communities, they are saving lives by providing health services and contributing to improved health outcomes while under the supervision of qualified health facility staff.
The Community Health Services Division continues to build a vibrant community-based interventions programme nationwide. Health workers and community health volunteers are trained to implement community case management activities. Community health activities are rapidly being scaled-up in all counties with the intent of changing the lives of the most vulnerable in the communities.
In 2011, the community-based programme was expanded and reinforced with support from partners. Data at the community level revealed that community health volunteers treated 363 tuberculosis cases in various communities. They also treated 7583 patients for malaria, 4333 for acute respiratory infection, 1625 for diarrhoea, while 600 complicated cases were referred to health facilities for treatment (369 for malaria, 119 for acute respiratory infection and 112 for diarrhoea) in the Integrated Community Case Management project in four counties (Bong, Gbarpolu, Lofa and Nimba).
Community health volunteers assessed 95 961 cases, treated 64 851 (41 547 for diarrhoea, 13 374 for acute respiratory infection and 5397 for malaria) and referred 31 110 patients to health facilities nationwide.